Journal Club

1. Journal Club Hunt K, Wyke S, Gray CM, Anderson AS, Brady A, Bunn C, Donnan PT, Fenwick E, Grieve E, Leishman J, Miller E, Mutrie N, Rauchhaus P, White A, Treweek S. A gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs (FFIT): a pragmatic randomised controlled trial. Lancet. 2014 Jan 20. pii: S0140-6736(13)62420-4. Cunningham SA, Kramer MR, Narayan KM. Incidence of childhood obesity in the United States. N Engl J Med. 2014 Jan 30;370(5):403-11 埼玉医科大学　総合医療センター　内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 松田　昌文　 Matsuda, Masafumi 2014年2月13日8:30-8:55 ８階　医局

2. Football Fans in Training (FFIT) is a weight loss and healthy living programme delivered to fans in Scottish professional football clubs under the auspices of the Scottish Premier League (SPL) trust, which became the Scottish Professional Football League (SPFL) trust in June, 2013. The Scottish Football League and The Scottish Premier League merged to create a single body to govern the 42 league clubs in Scotland. http://www.fifa.com/associations/association=sco/

3. a Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK b Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK c Centre for Public Health Nutrition Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK d NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, UK e Division of Population Health Sciences, Medical Research Institute, University of Dundee, Dundee, UK f Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK g NHS Forth Valley, Boness, UK h Scottish Premier League Trust, Hampden Park, Glasgow, UK i Moray House School of Education, University of Edinburgh, Edinburgh, UK j Centre for Men's Health, Faculty of Health and Social Science, Leeds Metropolitan University, Leeds, UK k Health Services Research Unit, University of Aberdeen, Health Sciences Building, Aberdeen, UK http://dx.doi.org/10.1016/S0140-6736(13)62420-4

4. Background The prevalence of male obesity is increasing but few men take part in weight loss programmes. We assessed the effect of a weight loss and healthy living programme on weight loss in football (soccer) fans.

5. Methods We did a two-group, pragmatic, randomised controlled trial of 747 male football fans aged 35–65 years with a body-mass index (BMI) of 28 kg/m2 or higher from 13 Scottish professional football clubs. Participants were randomly assigned with SAS (version 9·2, block size 2–9) in a 1:1 ratio, stratified by club, to a weight loss programme delivered by community coaching staff in 12 sessions held every week. The intervention group started a weight loss programme within 3 weeks, and the comparison group were put on a 12 month waiting list. All participants received a weight management booklet. Primary outcome was mean difference in weight loss between groups at 12 months, expressed as absolute weight and a percentage of their baseline weight. Primary outcome assessment was masked. Analyses were based on intention to treat. The trial is registered with Current Controlled Trials, number ISRCTN32677491.

7. ProceduresThe development, optimisation, and content of the FFIT programme is described elsewhere.14 Briefly, the programme was designed to work with rather than against prevailing understandings of masculinity.13, 14 and 17 The programme was gender sensitised in relation to context (the traditionally male environment of football clubs and men only groups), content (information about the science of weight loss presented simply, discussion of alcohol and its potential role in weight management, and branding with club insignia), and style of delivery (participative and peer-supported, which is learning that encouraged male banter to help with discussion of sensitive subjects). FFIT was delivered free of charge to participants by community coaching staff employed by clubs, trained over 2 days by the research team, to groups of up to 30 overweight or obese men (participant to coach ratio 15:1) during sessions every week for 12 weeks at the club's home stadium. Each 90 min session combined advice on healthy diet with physical activity. The balance of classroom and physical activity sessions changed during the 12 weeks; later weeks focused on physical activity as men became fitter, and the shorter classroom sessions focused on revision. Coaches were available at the end of each session if any man wanted to discuss personal issues. Participants were also taught behavioural change techniques known to be effective in physical activity, and dietary interventions (eg, self-monitoring, specific goal setting, implementation intentions, and feedback on behaviour),18 and social support was promoted. The 12 week active phase was followed by a weight maintenance phase with six post-programme email prompts during 9 months and a group reunion at the club 6 months after the end of the sessions.

8. Date, time and venue: Coaches: No. of men and layout of room: Session delivery protocol/recommended timings 1. Welcome back/2 minutes A warm welcome for making it to the second session can be a great boost to men’s confidence and feeling of self-worth. People feel valued if you acknowledge their presence. Important to start on time and encourage all men to interact from the outset. 2. Food diaries/5 minutes Immediately raising the homework gives people a sense that the work starts now! Invite the men to say a bit about how the food diary homework went. Was it easy or difficult? Did they eat what they thought they ate or were there any surprises? . 3. Eating well/25 minutes Preparation: The Eatwell plate mat with a display of foods representing each of the food groups should be prepared beforehand. Use the Eatwell display to talk through the concept of the five food groups and the different proportions from each group that make up a healthy diet. Take time to illustrate both the proportions recommended for each food group and the portion sizes for the foods represented. Discuss how this compares to what they would normally eat. Now, ask each person to look at their own food diary and write down the number of portions they had from each food group. Then encourage the men to discuss the results as a group. Were there any surprises? Did they notice which foods they ate too much of, and which they ate too little of? Gray et al.BMC Public Health 2013 13:232   doi:10.1186/1471-2458-13-232

9. 4. Setting goals/10 minutes Ask the men, in pairs, to think about their food diaries and each write down two goals that would help them achieve a more balanced diet. Stress their goals should be SMART (specific, measurable and achievable, realistic and time limited), give examples of SMART goals, and warn against setting huge, unrealistic goals that will only set them up to fail. Check that everyone has set two goals and convey your optimism to the group that they will succeed in meeting their goals. 5. Pedometer steps/20 minutes Moving on from the food-based discussion to a review of the men’s physical activity helps to reinforce the link between the two major aspects of the programme – “eating a healthier, more balanced diet” and “being active”. Refer to the men’s “Baseline steps” homework and ask the men how they found recording their daily steps. Explain that while how much we walk is dependent on a variety of factors, in general if you walk less than 5,000 steps a day this is seen as fairly sedentary, while if you record more than 10,000 steps this is seen as quite active. Ask the men to set a goal related to physical activity over the next week. Suggest that this may involve increasing their steps by an extra 1500 a day on three days of the week, and make sure they know where to record this. Discuss tips for increasing walking. . 6. Active session/28 minutes Consider another walk in the stadium (e.g., round the pitch)

11. The cost calculation for health economic assessment consisted of resources needed to manage and run the programme according to the price paid for them in September, 2011 (appendix). Additionally, at each measurement point we obtained self-reported data relating to the number and type of any NHS resources used in the preceding 12 weeks. Unit costs for visits to a general practitioner, practice nurse, or physiotherapist and attendance at accident and emergency were taken from Personal Social Services Research Unit 2011–12.24 Unit costs for inpatient stays and outpatient visits were taken from Information Services Division Scotland tariffs for 2012 and, as necessary, NHS reference costs for 2011–12. Unit costs for prescriptions for antidepressants, painkillers, asthma, pain gels and creams, anti-inflammatories, and sleeping tablets were taken from a typical prescription of each type from the British National Formulary. The area under the curve method was used to provide an estimate of costs for the within-trial period (ie, 1 year) from the two 12 week periods of data.25

17. The total costs associated with the intervention group were estimated as £254 579 (US$417 120) (£680 per participant), compared with total costs for the no intervention group of £177 025 (US$290 050) (£475 per participant), which is an incremental cost of £77 554 or £205 per individual (95% CI 27–386). This cost is driven mostly by the additional cost of the intervention. The cost-effectiveness of FFIT was estimated as £862 per additional man achieving and maintaining a 5% weight reduction at 12 months. The programme was also associated with a gain in QALYs of 0·015 (0·003–0·027) and an incremental cost-effectiveness of £13 847 per QALY gained. The cost-effectiveness acceptability curve (appendix) shows the probability that the intervention is cost-effective for any given value of the cost-effectiveness threshold. For a cost-effectiveness threshold of £20 000 per QALY, the probability that FFIT is cost-effective, compared with no intervention, is 0·72. This probability rises to 0·89 for a cost-effectiveness threshold of £30 000 per QALY. QALY=quality adjusted life year

19. Fenwick, E. and O'Brien, B.J. and Briggs, A. (2004) Cost-effectiveness acceptability curves - facts, fallacies and frequently asked questions. Health Economics 13(5):pp. 405-415. http://eprints.gla.ac.uk/4159/1/4159.pdf

20. Eight serious adverse events were reported, five in the intervention group (lost consciousness due to drugs for pre-existing angina, gallbladder removal, hospitalised with suspected heart attack, ruptured gut, and ruptured Achilles tendon), and three in the comparison group (transient ischaemic attack and two deaths, but we did not ask families for further details). Only two were reported as related to participation in the programme: the participant who ruptured an Achilles tendon did so while playing football during the FFIT programme; the participant who had his gallbladder removed was told by his doctor that his intermittent abdominal pains from gallstones could have been aggravated or caused by weight or dietary changes.

21. Findings 374 men were allocated to the intervention group and 374 to the comparison group. 333 (89%) of the intervention group and 355 (95%) of the comparison group completed 12 month assessments. At 12 months the mean difference in weight loss between groups, adjusted for baseline weight and club, was 4·94 kg (95% CI 3·95–5·94) and percentage weight loss, similarly adjusted, was 4·36% (3·64–5·08), both in favour of the intervention (p<0·0001). Eight serious adverse events were reported, five in the intervention group (lost consciousness due to drugs for pre-existing angina, gallbladder removal, hospital admission with suspected heart attack, ruptured gut, and ruptured Achilles tendon) and three in the comparison group (transient ischaemic attack, and two deaths). Of these, two adverse events were reported as related to participation in the programme (gallbladder removal and ruptured Achilles tendon).

22. Interpretation The FFIT programme can help a large proportion of men to lose a clinically important amount of weight; it offers one effective strategy to challenge male obesity. Funding Scottish Government and The UK Football Pools funded delivery of the programme through a grant to the Scottish Premier League Trust. The National Institute for Health Research Public Health Research Programme funded the assessment (09/3010/06).

23. Message 過体重と肥満の男性サッカーファン748人を対象に、スコットランドのプロサッカークラブのコーチによる減量と健康的な生活プログラム（FFIT）の介入効果を実践的無作為化比較試験で検証。12カ月後、対照群に比べ介入群で体重が減少し、調整後の減量の平均差は4.94kg、減量率の平均差は4.36％だった（いずれもP＜0.0001）。

25. 肥満小児の割合（日本）

26. the Hubert Department of Global Health (S.A.C., K.M.V.N.) and the Department of Epidemiology (M.R.K.), Emory University, Atlanta. N Engl J Med 2014;370:403-11.

27. Background Although the increased prevalence of childhood obesity in the United States has been documented, little is known about its incidence. We report here on the national incidence of obesity among elementary-school children

28. Methods We evaluated data from the Early Childhood Longitudinal Study, Kindergarten Class of 1998–1999, a representative prospective cohort of 7738 participants who were in kindergarten in 1998 in the United States. Weight and height were measured seven times between 1998 and 2007. Of the 7738 participants, 6807 were not obese at baseline; these participants were followed for 50,396 person-years. We used standard thresholds from the Centers for Disease Control and Prevention to define “overweight” and “obese” categories. We estimated the annual incidence of obesity, the cumulative incidence over 9 years, and the incidence density (cases per person-years) overall and according to sex, socioeconomic status, race or ethnic group, birth weight, and kindergarten weight.

30. Figure 1. Prevalence and Incidence of Obesity between Kindergarten and Eighth Grade. Shown are the age-specific prevalence of overweight and obesity (left graph on each panel) and annual incidence of obesity according to the weight status at baseline (right graph on each panel) among boys (Panel A) and girls (Panel B). The black vertical lines and I bars represent 95% confidence intervals.

33. Results When the children entered kindergarten (mean age, 5.6 years), 12.4% were obese and another 14.9% were overweight; in eighth grade (mean age, 14.1 years), 20.8% were obese and 17.0% were overweight. The annual incidence of obesity decreased from 5.4% during kindergarten to 1.7% between fifth and eighth grade. Overweight 5-year-olds were four times as likely as normal-weight children to become obese (9-year cumulative incidence, 31.8% vs. 7.9%), with rates of 91.5 versus 17.2 per 1000 person-years. Among children who became obese between the ages of 5 and 14 years, nearly half had been overweight and 75% had been above the 70th percentile for body-mass index at baseline.

34. Conclusions Incident obesity between the ages of 5 and 14 years was more likely to have occurred at younger ages, primarily among children who had entered kindergarten overweight. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.)

35. Message 米国で1998年に幼稚園に入園した7738人のデータを対象に、小児期（5-14歳）の肥満発生率を前向きコホート研究で調査。5万396人年の追跡の結果、肥満の年間発生率は幼稚園児の5.4％から5-8年生では1.7％へ低下した。過体重の5歳児が肥満になる確率は正常体重児の4倍だった（9年間累積発生率31.8％対7.9％）。